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Abstract: Intracranial hemorrhage is a potentially life-threatening condition categorized into four main groups by the location of bleeding: epidural, subdural, subarachnoid, and intraparenchymal. Subdural hematoma (SDH) is increasingly common as the population of older adults increases. Clinicians must recognize the typical presentations and order diagnostic imaging studies to make a timely diagnosis and referral to neurosurgery for definitive treatment. Understanding the pathophysiology and risk factors for chronic or expanding SDH informs decision-making in managing anticoagulants. Emerging treatments offer potential alternatives to the traditional evacuation of SDH by craniotomy, which remains the standard of care for most symptomatic patients., (Copyright © 2024 American Academy of Physician Associates.)

Subdural hemorrhages (SDHs) in the pediatric population are associated with a high mortality and morbidity and may present in the context of abusive head trauma. Diagnostic investigations for such cases often include evaluation for rare genetic and metabolic disorders that can have associated SDH. Sotos syndrome is an overgrowth syndrome associated with macrocephaly and increased subarachnoid spaces and rarely with neurovascular complications. Here, we report two cases of Sotos syndrome, one with SDH during infancy who underwent repeated evaluation for suspected child abuse prior to the Sotos syndrome diagnosis and the other with enlarged extra-axial cerebrospinal fluid spaces, demonstrating a possible mechanism for SDH development in this setting. These cases suggest that some individuals with Sotos syndrome may be at elevated risk of developing SDH in infancy and that Sotos syndrome should be on the differential diagnosis during a medical genetics evaluation in cases of unexplained SDH, especially in the setting of macrocephaly., Competing Interests: None declared., (Thieme. All rights reserved.)

Competing Interests: The authors report no conflicts of interest.

Objectives: Seizures and status epilepticus (SE) are frequent complications of acute subdural hematoma (aSDH) associated with increased morbidity and mortality. Therefore, we aimed to evaluate whether invasive subdural electroencephalogram recording leads to earlier seizure detection and treatment initiation in patients with aSDH., Design: Prospective, single-center, cohort trial., Setting: Neurologic and neurosurgical ICUs of one academic hospital in Germany., Patients: Patients with aSDH undergoing surgical treatment. In total, 76 patients were enrolled in this study, 31 patients (40.8%) were assigned to the invasive electroencephalogram (iEEG) monitoring group and 45 patients (59.2%) to control group., Interventions: The electrode group was implanted with a subdural strip electrode providing up to 7 days of real-time electroencephalogram recording in the neurointensive care unit, whereas the control group received regular normal surface electroencephalograms during the 7-day period. The primary outcomes were the prevalence and time to seizures and SE occurrence. Secondary outcomes included neurologic outcomes assessed using the Glasgow Outcome Scale (GOS) at discharge and 6-month follow-up and the prevalence of focal structural epilepsy within 2 years after discharge., Measurements and Main Results: The trial was stopped after a study committee meeting when the prespecified criteria were met. The iEEG and control groups were well-matched for clinical characteristics at admission. Frequencies of seizures and SE detection were significantly higher in the iEEG group than in the control group (61% vs 15.6%; p < 0.001 and 38.7% vs 11.1%; p = 0.005). Time to seizure and SE detection was significantly earlier (median 29.2 vs 83.8 hr; p = 0.018 and 17.2 vs 83.8 hr; p = 0.033) in the iEEG group than in the control group. Favorable outcomes (GOS 4-5) were more frequently achieved in the iEEG group than in the control group (58% vs 31%; p = 0.065). No significant differences were detected in long-term mortality or post-traumatic epilepsy., Conclusions: Invasive subdural electroencephalogram monitoring is valuable and safe for early seizure/SE detection and treatment and might improve outcomes in the neurocritical care of patients with aSDH., Competing Interests: Drs. Rosenow and Strzelczyk received funding from Angelini Pharma and Desitin Arzneimittel. Dr. Rosenow’s institution received funding from Federal State of Hesse; he received funding from Eisai GmbH, Jazz Pharma, UCB Pharma, and Roche Pharma; and he received support for article research from Federal State of Hesse. Dr. Strzelczyk received funding from GW/Jazz Pharmaceuticals, Eisai, Marinus, Takeda, UCB/Zogenix, and UNEEG medical. Dr. Melzer has received honoraria for lecturing and travel expenses for attending meetings from Biogen Idec, GlaxoSmithKline, Teva, Novartis Pharma, Bayer Healthcare, Fenzyme, Alexion Pharmaceuticals, Fresenius Medical Care, Diamed, UCB Pharma, Angelini Pharma, and BIAL; he has received royalties for consulting from USB Pharma and Alexion Pharmaceuticals; and he has received support from Euroimmun Fresenius Medical Care, Diamed, Alexion Pharmaceuticals, and Novartis Pharma. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2023 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

Background: This study aimed to investigate the application of deep learning (DL) models for the detection of subdural hematoma (SDH)., Methods: We conducted a comprehensive search using relevant keywords. Articles extracted were original studies in which sensitivity and/or specificity were reported. Two different approaches of frequentist and Bayesian inference were applied. For quality and risk of bias assessment we used Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2)., Results: We analyzed 22 articles that included 1,997,749 patients. In the first step, the frequentist method showed a pooled sensitivity of 88.8% (95% confidence interval (CI): 83.9% to 92.4%) and a specificity of 97.2% (95% CI 94.6% to 98.6%). In the second step, using Bayesian methods including 11 studies that reported sensitivity and specificity, a sensitivity rate of 86.8% (95% CI: 77.6% to 92.9%) at a specificity level of 86.9% (95% CI: 60.9% to 97.2%) was achieved. The risk of bias assessment was not remarkable using QUADAS-2., Conclusion: DL models might be an appropriate tool for detecting SDHs with a reasonably high sensitivity and specificity., Competing Interests: Competing interests: AM: Speakers Bureau/Consultant to Cerenovus, Stryker, Wallaby Medical, RapidAI, BALT USA, LLC. This study did not receive funds from these companies/institutes., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Although there is research regarding the diagnosis and timing of abusive head trauma, there remains practice variation among pediatric subspecialists., Objectives: To examine diagnostic variability among pediatric subspecialists using case examples of infant head injury. Secondary objectives were timing variability among subspecialists, and diagnostic and timing variability among Child Abuse Pediatricians (CAPs)., Participants and Setting: Pediatric subspecialists were recruited from Child Abuse Pediatrics, Hospital Medicine, Emergency Medicine, Critical Care, and Neurosurgery to complete a research instrument. Participants qualified for the study if they evaluated at least 1 case of possible abusive head trauma during their career., Methods: This multi-institutional, mixed-methods study used a research instrument with 4 case examples of infant head injury: severe retinal hemorrhages (RH), mass-effect subdural hemorrhage (SDH), SDH membrane formation, and sepsis. The response selected by most CAPs was reference and compared across subspecialties and among CAPs using Chi-square or Fisher's exact tests. A Bonferroni correction (p < 0.01) was used for subspecialty comparisons., Results: There were 288 participants who completed at least 1 case example. Diagnostic variability was observed in all case examples. Significantly fewer Hospital Medicine (34.9 % vs. 57.9 %, p < 0.01), Emergency Medicine (28.0 % vs. 57.9 %, p < 0.0001), and Neurosurgery (24.0 % vs. 57.9 %, p < 0.01) participants selected the reference response for the mass-effect SDH case example. Timing variability was statistically significant for all case examples (p < 0.01). Significantly fewer CAPs aged 44-64 years selected the reference response for timing (p < 0.01) for the severe RH case example., Conclusions: Additional peer review processes and consensus guidelines for challenging issues in abusive head trauma may be beneficial., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: Multisystem Inflammatory Syndrome in Neonates (MIS-N) can occur following antenatal COVID- 19 infection in the mother. Here we report a rare case of a neonate with Hemophilia A and MIS-N., Case Presentation: A 2-day-old baby presented with an intramuscular hematoma, neonatal seizures, and isolated activated partial thromboplastin time (APTT) prolongation. The neurosonogram showed a subdural hematoma. A diagnosis of Hemophilia A was made and was confirmed by factor 8 assay and genetic analysis. Supportive measures and Factor 8 replacement was initiated. A rising trend of inflammatory markers and an ongoing need for mechanical ventilation were noted. As there was a history of COVID-19 in the mother in the third trimester, MIS-N was diagnosed. The baby was treated with intravenous immunoglobulin (IVIG) and steroids, and there was an improvement in the clinical and laboratory markers. However, the baby developed seizures on day 16. There was an increase in the subdural hemorrhage and a further rise in inflammatory markers. A craniostomy and hematoma evacuation was done and the baby improved., Conclusion: The concurrent occurrence of hemophilia A with intracranial bleed, and MIS-N in a neonate is a diagnostic challenge. It is important to have a high index of suspicion to ensure timely diagnosis and treatment of MIS-N in this pandemic era., (© 2022. The Author(s).)

Spontaneous intracranial hypotension typically manifests with orthostatic headaches and is caused by spinal dural tears, ruptured meningeal diverticula, or CSF-venous fistulas. While most patients are diagnosed and treated in the outpatient setting, some patients will occasionally present in the emergent ICU setting due to subdural hematomas, coma, or downward brain herniation. In this review paper, we will discuss the diagnostic and treatment steps that intensivists can undertake to coordinate a team approach to successfully manage these patients. A brief general overview of spontaneous intracranial hypotension will also be discussed.

Objective: Risk factors for mortality in patients with subdural hematoma (SDH) include poor Glasgow Coma Scale (GCS) score, pupil nonreactivity, and hemodynamic instability on presentation. Little is published regarding prognosticators of SDH in the elderly. This study aims to examine risk factors for hospital mortality and withdrawal of life-sustaining measures in an octogenarian population presenting with SDH., Methods: A prospectively collected multicenter database of 3279 traumatic brain injury admissions to 45 different U.S. trauma centers between 2017 and 2019 was queried to identify patients aged >79 years old presenting with SDH. Factors collected included baseline demographic data, past medical history, antiplatelet/anticoagulant use, and clinical presentation (GCS, pupil reactivity, injury severity scale [ISS]). Primary outcome data included hospital mortality/discharge to hospice care and withdrawal of life-sustaining measures. Multivariate logistic regression analyses were used to identify factors independently associated with primary outcome variables., Results: A total of 695 patients were isolated for analysis. Of the total cohort, the rate of hospital mortality or discharge to hospice care was 22% (n = 150) and the rate of withdrawal of life-sustaining measures was 10% (n = 66). A multivariate logistic regression model identified GCS <13, pupil nonreactivity, increasing ISS, intraventricular hemorrhage, and neurosurgical intervention as factors independently associated with hospital mortality/hospice. Congestive heart failure (CHF), hypotension, GCS <13, and neurosurgical intervention were independently associated with withdrawal of life-sustaining measures., Conclusions: Poor GCS, pupil nonreactivity, ISS, and intraventricular hemorrhage are independently associated with hospital mortality or discharge to hospice care in patients >80 years with SDH. Pre-existing CHF may further predict withdrawal of life-sustaining measures., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Based on a patient encounter in which genetically confirmed Marfan's syndrome (MFS) underlay a spontaneously resolving subdural hygroma (SDHy) diagnosed in infancy, we review the literature of MFS clinically manifest in early life (early-onset MFS [EOMFS]) and of differential diagnoses of SDHy and subdural hemorrhage (SDHe) at this age. We found that rare instances of SDHy in the infant are associated with EOMFS. The most likely triggers are minimal trauma in daily life or spontaneous intracranial hypotension. The differential diagnosis of etiologies of SDHy include abusive and nonabusive head trauma, followed by perinatal events and infections. Incidental SDHy and benign enlargement of the subarachnoid spaces must further be kept in mind. SDHy exceptionally also may accompany orphan diseases. Thus, in the infant, EOMFS should be considered as a cause of SDHe and/or SDHy. Even in the absence of congestive heart failure, the combination of respiratory distress syndrome, muscular hypotonia, and joint hyperflexibility signals EOMFS. If EOMFS is suspected, monitoring is indicated for development of SDHe and SDHy with or without macrocephaly. Close follow-up is mandatory., Competing Interests: No author has any conflict of interest to declare., (Thieme. All rights reserved.)

Competing Interests: The authors declare no conflict of interest.

Background: Patients undergoing a subdural hematoma (SDH) evacuation can experience transient neurological symptoms (TNS) postoperatively. Electroencephalography (EEG) is used to rule out seizures. We aim to characterize patients with TNS and negative epileptiform activity on EEG and compare them to those with positive epileptiform EEG findings., Methods: We performed a retrospective study of adult patients who underwent EEG for evaluation of TNS after undergoing SDH evacuation. Patients were stratified based on SDH type (acute and non-acute) and whether or not their EEG demonstrated positive epileptiform activity. A multivariate analysis was performed to identify predictors of negative EEG findings., Results: One hundred twenty-nine SDH patients were included (45 (34.9%) acute; 84 (65.1%) non-acute). Overall, 45 (24 acute and 21 non-acute SDH patients) had positive epileptiform EEG findings, and 84 (21 acute and 63 non-acute SDH patients) had a negative EEG. Acute and non-acute SDH patients with positive EEG findings were more likely to suffer from greater than five episodes of TNS, impaired awareness, and motor symptoms, while the negative EEG group was more likely to suffer from negative symptoms. Non-acute SDH patients with positive EEG had longer mean ICU stays (14.6 vs. 7.2; p = 0.005). Both acute and non-acute SDH-positive EEG patients had worse disposition upon discharge (p < 0.05), worse modified Rankin score at discharge (p < 0.05), and 3-month follow-up (p < 0.05) and were more likely to be discharged on more than one antiepileptic drug (p < 0.001)., Conclusion: Postoperative acute and non-acute SDH patients with TNS and negative EEG results are likely to have a favorable clinical picture. This distinction is therapeutically and prognostically important as these patients may not respond to typical antiepileptic drugs and they have better functional outcomes., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)